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I had just finished teaching a day-long crash course in basic emergency care. My students were general practitioners and nurses at a small district hospital in a lakeside town on the edge of Rwanda. There are no specialists in these hospitals, only generalists who rotated between the wards, labor and delivery, and the emergency department. My co-workers and I wanted to check out how the nascent emergency department at this hospital was functioning. This wasn’t the first district hospital I’d visited, and I spent a fair amount of time helping the government develop their emergency systems, so I already had a sense of what I’d see. Maybe some semblance of a triage system, but likely not working well. Most critical medication in supply, no working cardiac monitors, kind and caring staff who have never known the need to run to a patient’s room. Some good points, lots to work on.
When we walked in, I noticed an old man lying in a stretcher. He was quiet, thin, with a vacant look. You wouldn’t have seen him if you hadn’t been looking. My spidey sense went off and on closer inspection the man was tachypneic, tachycardic, felt warm to the touch.
Sick/not sick. The first and most important lesson in residency is developing the ability to distinguish this. Most of it is well-honed observation skills, attention to vital signs, and pattern recognition. We asked what he was there for and were told he had a low blood sugar. The nurses had started an IV and hung a bag of D5. How low was his sugar? Really low. When did you hang the D5? 30 minutes ago. Barely a drop had gone in, the IV was kinked.
My Rwandan emergency resident moved into action, with the confidence of his training and started calling the nurses over to give them orders in Kinyarwanda. Push an amp of D50. Hang a liter of NS wide open. Check his temperature and blood pressure; what antibiotics do we have? As the nurses started to carry out these request the man’s thready pulse went absent.
CPR, while rarely effective in the United States, probably has minimal utility in a place like that ED. But it was a reflex response, and besides he lost pulses right in front of us. A few minutes of CPR with fluids and sugar and epi might work. We tried, but failed to get that pulse back. The doctor running the department walked in about halfway through the code, genuinely concerned, but also more than a little annoyed. Not at us, but that the system hadn’t worked for this patient. These doctors, out past the hills and rainforests, work tirelessly just to get some parts of the system to work. We often complain in the US how our healthcare system is broken. In many parts of the world, the healthcare system barely exists.
Whenever someone quips that they feel safer that an EM doctor is around, I usually respond by noting that I am of relatively little use without a functioning department around me. I can do CPR, make some visual diagnoses, offer assurance and guidance to the worried well. But to the true emergency patients, intubation skills don’t
matter if you don’t have a tube and a respirator, pharmacological decisions don’t matter if you don’t have the drugs, and all the knowledge in the world doesn’t matter if you don’t have the triage system to get the sickest people in front of you, capable nurses to work alongside you, a hospital to admit patients to, and a functioning healthcare system turning all the gears beyond the hospital walls.
I’ve always had an interest in improving health care in low-income countries. That interest had brought me to Rwanda in the first place. But with that quiet man on the edge of Rwanda drove home how important and interconnected every link in the system is. The pioneers of emergency medicine in places like Rwanda have to not only develop their expertise, they have to build entire healthcare systems in their wake. As we celebrate the strides we have made in the US where this movement started, I think of how that movement is just getting started for most of the planet. May we recognize our place in the global community of emergency providers, and embrace our place in moving it forward.
